At Blue MountainWellness, we care about you as a person. We are NOT here to judge. We are here to guide and support you. Our path to work together for sensible, maintainable, weight loss begins with honestly filling out this form. We are excited to start that journey with you!

Personal Contact Information

First Name * This field is required.

Last Name * This field is required.

Address * This field is required.

City * This field is required.

State * This field is required.

Postal code * This field is required.

Phone * This field is required.

Email * This field is required.

Today's Date *

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Patient Gender * This field is required.

Date of birth *

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Height * This field is required.

Starting Weight * This field is required.

Marital Status *

Marital Status

Single
Married
Widowed
Separated
Divorced
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Occupation * This field is required.

How did you hear about us? *

How did you hear about us?

Facebook
Friend
Fishwrapper
Bilboard
Radio/Tv
Youtube
Google
Merchandiser
Other
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General Health and Wellness History

Are you currently under the care of a physician? *

Are you currently under the care of a physician?

Yes
No
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Are you taking any medications? *

Are you taking any medications?

Yes
No
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If yes, please specify the medications you are taking This field is required.

Personal Health: (Check all that apply) *

Personal Health: (Check all that apply)

Stroke
Diabetes
High BP
Weight Problems
Depression
Ulcer
Heart Disease
Thyroid Issues
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Has your doctor advised you to lose weight? *

Has your doctor advised you to lose weight?

Yes
No
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Do you have any dietary restrictions? *

Do you have any dietary restrictions?

Yes
No
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If Yes, please explain any dietary restrictions? * This field is required.

How often do you exercise? What type of exercise? This field is required.

Do you feel stressed? *

Do you feel stressed?

Yes
No
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If yes, please explain how you feel stressed? This field is required.

Does your weight problem cause physical pain? *

Does your weight problem cause physical pain?

Yes
No
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If Yes, explain how your weight problem cause physical pain? This field is required.

Average Hours of Sleep per night *

Average Hours of Sleep per night

<1
1-3
3-6
6-8
8-10
>10
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What else is there about either your history or current condition that you feel you would like to tell us. * This field is required.

Diet Information and History

List any food aversions and/or foods you don’t eat * This field is required.

What have you done in the past to lose weight? How long ago? How successful or unsuccessful were you? * This field is required.

Are you embarrassed by your weight or does it limit your desire to participate in activities?

Yes
No
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What is your biggest obstacle to weight loss? * This field is required.

Psychological Impact of Your Weight Relationship with Food

Does your weight problem make you physically uncomfortable? *

Does your weight problem make you physically uncomfortable?

Yes
No
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If yes, describe how your weight problem make you physically uncomfortable This field is required.

Do you feel that food controls you? *

Do you feel that food controls you?

Yes
No
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Does being overweight and unhealthy limit your activities? *

Does being overweight and unhealthy limit your activities?

Yes
No
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Do you binge eat? *

Do you binge eat?

Yes
No
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If yes, what do you binge eat? This field is required.

Do you suffer from uncontrollable cravings? *

Do you suffer from uncontrollable cravings?

Yes
No
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If yes, what do you crave? This field is required.

Do you eat because of your emotions? *

Do you eat because of your emotions?

Yes
No
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Do you eat between meals? *

Do you eat between meals?

Yes
No
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Personal Goals

Please answer the following questions honestly so we can do our best to help you reach your goals. Check ALL areas of treatment that interest you: *

Please answer the following questions honestly so we can do our best to help you reach your goals. Check ALL areas of treatment that interest you:

Weight Loss
Cleansing and Detoxification
General Wellness
More Energy
Stress Reduction
Other
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Does your family support your weight loss efforts? *

Does your family support your weight loss efforts?

Yes
No
Unsure
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What do you consider to be your ideal weight? * This field is required.

How much weight do you want to lose? * This field is required.

Signature Date *

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To what extent are you willing to commit to achieving better health? *

To what extent are you willing to commit to achieving better health?

Little
Moderate
Major
Extreme
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I understand that my entire patient history will remain completely confidential and will not be released without express written consent from me. *

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